Workers Comp Audit Stress Reducer
Use It For Your Next Premium Audit

Medical Only Claims – Worst Type May Go Unnoticed Festering


The Very Worst Workers Comp Medical Only Claims

Recently, I posted on the pitfalls of Workers Comp medical only claims. That article is here. The worst medical only claims nightmare results from claims festering – or an unknown claim that sits with undiscovered liability.

Picture Of Doctor Medical Only Claims Explaining In Patient
Wikimedia Commons – Jorgejesus4

There is a very small window of time where a claim can be investigated – regardless of whether it is a medical only or a lost time Workers Comp claim. The three-point contact (Employer, Employee, and Medical Provider) must be made within 24 hours. This allows for a timely and proper accept/deny decision.

If an employee has not drawn Workers Comp benefits, these claims are usually lumped into the Medical Only category. There are a few exceptions.

Medical benefits are paid timely, but the claim is becoming more serious without any monitoring. The medical bill expense may not necessarily signal any problems if the injured employee keeps working and only has medical office visit and prescription expenses.   The claims staff usually does not contact the injured employee in these cases.

Doctor Talking To Patient Medical Only Claims In Hospital Bed

Who monitors these claims? The answer is usually no one.   The medical bills are processed and the claims just keep growing and growing with no intervention.

2023 Update

Some systems automatically monitor and flag the lost time adjuster that a med-only file has reached a certain reserve limit; days without closing, or other variables that indicate a much more serious claim that when originally opened at the start of the claim.

Yes, there is a med-only adjuster than may alert their supervisors on a few of these types of claims. They are usually too overloaded with volume to read every medical report.

Med-Only Claims Adjuster Is Key

A talented Medical Only claims adjuster spots this type of claim early in the process.   Do not ever think these adjusters are not that important.  Heading off a very serious case of claims festering(c) saves massive claim payouts in the future.

The ability to spot these claims is an art unto itself. How does an employer monitor these claims? I will cover that next time.

©J&L Risk Management Inc Copyright Notice



James J Moore - Workers Comp Expert

Raleigh, NC, United States

About The Author...

James founded a Workers’ Compensation consulting firm, J&L Risk Management Consultants, Inc. in 1996. J&L’s mission is to reduce our clients’ Workers Compensation premiums by using time-tested techniques. J&L’s claims, premium, reserve and Experience Mod reviews have saved employers over $9.8 million in earned premiums over the last three years. J&L has saved numerous companies from bankruptcy proceedings as a result of insurance overpayments.

James has over 27 years of experience in insurance claims, audit, and underwriting, specializing in Workers’ Compensation. He has supervised, and managed the administration of Workers’ Compensation claims, and underwriting in over 45 states. His professional experience includes being the Director of Risk Management for the North Carolina School Boards Association. He created a very successful Workers’ Compensation Injury Rehabilitation Unit for school personnel.

James’s educational background, which centered on computer technology, culminated in earning a Masters of Business Administration (MBA); an Associate in Claims designation (AIC); and an Associate in Risk Management designation (ARM). He is a Chartered Financial Consultant (ChFC) and a licensed financial advisor. The NC Department of Insurance has certified him as an insurance instructor. He also possesses a Bachelors’ Degree in Actuarial Science.

LexisNexis has twice recognized his blog as one of the Top 25 Blogs on Workers’ Compensation. J&L has been listed in AM Best’s Preferred Providers Directory for Insurance Experts – Workers Compensation for over eight years. He recently won the prestigious Baucom Shine Lifetime Achievement Award for his volunteer contributions to the area of risk management and safety. James was recently named as an instructor for the prestigious Insurance Academy.

James is on the Board of Directors and Treasurer of the North Carolina Mid-State Safety Council. He has published two manuals on Workers’ Compensation and three different claims processing manuals. He has also written and has been quoted in numerous articles on reducing Workers’ Compensation costs for public and private employers. James publishes a weekly newsletter with 7,000 readers.

He currently possess press credentials and am invited to various national Workers Compensation conferences as a reporter.

James’s articles or interviews on Workers’ Compensation have appeared in the following publications or websites:

  • Risk and Insurance Management Society (RIMS)
  • Entrepreneur Magazine
  • Bloomberg Business News
  • WorkCompCentral.com
  • Claims Magazine
  • Risk & Insurance Magazine
  • Insurance Journal
  • Workers Compensation.com
  • LinkedIn, Twitter, Facebook and other social media sites
  • Various trade publications


Get the latest workers' comp news FREE!

This field is for validation purposes and should be left unchanged.